1. The Limping Embryo: Toxic Synovitis

The Limping Embryo:
Toxic Synovitis.  

This is the first episode of our podcast, published on March 3, 2020.  Dr Arreaza explains the  format of the podcast and explains toxic synovitis.  

Episode 1 has a purposefully confusing name. Dr Arreaza briefly explains toxic synovitis and we introduce our sections Espanish Por Favor, Speaking Medical and For Your Sanity. 

The sun rises over the San Joaquin Valley, California, this week the Coronavirus is all over the internet. The official name is COVID-19. As of February 27, 2020, over 80,000 people are estimated to be infected with coronavirus worldwide, with about 2,700 deaths2. It is spreading fast. There are 60 confirmed cases of COVID-19 in the United States1. No deaths have been reported so far. The coronavirus story is developing as I talk right now. 

In the meantime, there are about 40 million people infected by Influenza A&B (yes, 40 million), which have caused about 40,000 deaths around the world (40,000). Headlines about influenza A&B are less common these days.  

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Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.

The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach, and Serve. 

Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971.

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Hello everyone, this is our first episode of Rio Bravo qWeek Podcast, which I called “The limping embryo”. An embryo is the elemental stage of an organism which evolves into a baby and then becomes an adult. This is the first episode (the embryo) of many more episodes that will come. BUT Why is this a “LIMPING” embryo? I invite you to listen until the end to find out.

Let me introduce myself. My name is Hector Arreaza. As you can tell, I was not born in Minnesota or Oregon, and I’m reminded frequently about it when people ask me “Where are you from?”. The answer to that question is not easy, but I’ll try to keep it simple. I was born and raised in Venezuela (South America, or how some people may call it, “one of those Mexican countries”). I graduated from Medical school there, and when I was 24 years old, I served as a missionary in Salt Lake City, Utah. I went back to Venezuela for a few months and returned to the United States searching to further my education in a residency program. After spending some years as a Spanish translator, I found a residency spot in Bakersfield, California, where I completed a residency in Family medicine. I practiced primary care in a community health center for about 1 and a half years, and Dr Stewart, who is the program director of my residency program, offered me a position as faculty in the very same residency I graduated from. It has been over one year, and I am loving it.

This podcast has been created to promote teaching and learning among residents, medical students, and faculty, and whoever listens to us wherever you are in the world. I hope you can enjoy it. 

“What we know is a drop… what we do not know is an ocean.” (Isaac Newton) 

“What we know is a drop”. That little drop of knowledge that we know is becoming larger and larger over time. Medicine has experienced many advances recently, and it is complicated to keep up with all the knowledge available to us. The idea of this podcast is to provide some traces of knowledge, maybe a mini-micro-drop to complement your study during your residency.

During our podcast we will focus on 5 questions. A different guest will be invited to participate every week, and I will conduct the interview. The questions are:

Question Number 1: Who are you? (the interviewee will have about 20 seconds to introduce him or herself)

Question number 2: What did you learn today? (any topic is valid, the interviewee will explain what he or she learned, some additional questions may be asked to clarify the topic)

Question number 3: Why is that knowledge important for you and your patients? (practical application)

Question number 4: How did you get that knowledge? (learning habits)

Question number 5: Where did that knowledge come from? (cite source)

So, because this is the first episode, I want to follow the same pattern which I have established for the podcast. 

QUESTION NUMBER 1: Who are you? 

I already answered the first question about who I am. 

QUESTION NUMBER 2: What did you learn today?

Today, I learned about toxic synovitis. 

Toxic synovitis is the most common cause of acute hip pain and limp in children ages 2-12. 

Irritable hip is a non-specific term referring to acute limping, hip pain, and stiffness which may be used in clinical practice instead of toxic synovitis.

Toxic synovitis is a term that can be confusing for patients or even professionals who are unfamiliar with this condition, because it has nothing to do with a “toxic state or toxic appearance”. 

Other names are: Postinfectious arthritis, Transitory coxitis, Coxitis fugáx, Acute transient epiphysitis, but in general, a very appropriate name for this condition is transient synovitis. 

It is “transient”because it is a self-limited, inflammatory disorder of the hip (typically the hip, but it may affect other joints) affecting young children between ages 2-12, more commonly boys. 

Presentation: Typically presents with mild to moderate hip pain and limping with a history of recent upper respiratory infection (runny nose, cough, fever), which may not be always present, and it can be any kind of extraarticular viral infection, some examples: rubella, parvovirus B19, and coxsackie virus. 

The patient normally keeps his or her hip in abduction and external rotation, hip motion may be limited, but the patient will usually allow movement through a limited arc of motion. Normally the patient will be able to bear weight.

Evaluation: 

History and Physical exam are very important. Physical exam findings include hip pain with movement, and no external signs of inflammation.

Labs may include a Complete Blood Count, Erythrocyte Sedimentation Rate and C Reactive Protein, however, they are usually normal. Lab studies may be ordered to rule out other causes, especially septic arthritis.

X-ray of hip is normal, however, you can have minor changes: early radiographic signs may include capsular distention, joint space widening, decreased definition of soft tissue planes around the hip joint, or slight demineralization of the bone of the proximal femur. The primary role of plain radiographs is ruling out other disorders.

Ultrasound may detect joint effusion, and absent joint effusion rules out septic arthritis.

Differential Diagnosis: 

Septic arthritis, the most important condition to rule out. Septic arthritis presents with toxic appearance, the hip pain is more intense and elevation of inflammatory markers is present.

In transient synovitis, think about this 4 elements: Fever, weight bearing, ESR and serum WBC. 

Fever <101.3°F (<38.5°C)Child able to bear weightESR (erythrocyte sedimentation rate) < 40 mm/hourSerum white blood cell count <12,000 cells/mm³

 

Predicted probability of septic arthritis is <0.2% if you have all these elements, and 3.0% for only one predictor.

Other Differential Diagnosis: Lyme arthritis (late manifestation), Osteomyelitis, Legg-Calvé-Perthes disorder (pronunciation is questionable), Pyogenic sacroiliitis, Juvenile idiopathic arthritis, fractures, and tumors. 

Treatment: It is supportive with activity restrictions and NSAIDs as needed. Recurrence is not common. Observation in hospital may be warranted if septic arthritis needs to be ruled out. Follow up in 7-10 days is advised. 

A reminder: Transient synovitis is uncommon in adults, it is more common in fall and winter, less common in African American children, rarely bilateral, and if recurrent or persistent, it may be the initial feature of a chronic inflammatory condition such as juvenile idiopathic arthritis.

QUESTION NUMBER 3: Why is that knowledge important for you and your patients? 

As family Medicine physicians, we encounter all kind of complaints across all ages. Knowing how to approach hip pain in children allows you to provide appropriate and timely treatment for your patients. Misdiagnosis of hip pain, may cause serious consequences to your patients, including permanent disability. Using your clinical judgement to decide on the appropriate laboratory studies and imaging in hip pain allows you practice cost-effective, and accurate medicine.

QUESTION NUMBER 4: How did you get that knowledge?

I got interested in the topic because of an email I got from the New England Journal of Medicine titled Question of the Week3.

QUESTION NUMBER 5: Where did that knowledge come from? 

After answering the question of the week, I went deeper into the topic by reading the abstracts of the citations mentioned in the question: John J and Chandran L. “Arthritis in children and adolescents”. Pediatr Rev 2011, Nov, AND Huntley JS. “Diagnosing and managing hip problems in childhood”, 2013 5, 6, 7. See details in our website. 

I also consulted Online Epocrates4, which is a handy resource when you need a rapid review of a certain topic.

Remember transient synovitis is a diagnosis of exclusion of hip pain in children after an upper respiratory infection. And now you know why this episode was called “The Limping Embryo”.

Now we conclude our first episode “The Limping Embryo”, an embryonic podcast episode about limping. We hope our limping embryo turns into a flying eagle in the future, as this podcast continues to grow and evolve. 

Espanish Por Favor

The Spanish word of the week is Coyuntura. Coyuntura actually means joint; the type of joint that are made out of bones ok. The definition of joint is a structure in the human or animal body at which two parts of the skeleton are fitted together, coyuntura. Coyuntura is a common word among the elderly, although it’s not uncommon to hear it from younger people. People may use this word while explaining any pain in any joint. As an example, your patient may complain saying: “Doctor me duelen las coyunturas”. This translates “Doctor my joints hurt”; meaning most of their joints are hurting. Although they may also refer to a particular joint such as the hip or the knee or any other coyuntura. Now you know the Spanish word of the week, co-yun-tu-ra, and you know what it means, all you need to do now is to assess your patient’s coyunturas. 

 

For your Sanity

-How do you hide a one-hundred-dollar bill from a Family Medicine Resident?

-How?

–Well, you put it in their in basket/in-box

-LOL

 

-Ah, and how do you hide it from a Radiologist?

– I don’t know, I guess you put it in a dark room.

– Hahahah it’s a good answer but no, you give the dollar bill to the patient. LOL

 

– And how do you hide the one-hundred-dollar bill from a Plastic Surgeon?

– I have no clue.

– Yes, you are right, you can’t. You can’t hide money from a Plastic Surgeon. 

 

Speaking Medical

The medical word of the week is: Sphenopalatine ganglioneuralgia

Can you guess what that means? 

Wow. What a mouthful, huh.  A mouthful of ice cream that is!  Sphenopalatine ganglioneuralgia is the medical term for ‘brain freeze.’ The sphenopalatine ganglia is the largest of the 4 parasympathetic ganglia associated with the trigeminal nerve.  Consists of the largest collection of neurons in the head outside of the brain.

Sphenopalatine ganglioneuralgia is NOT considered a disease.  Vasoconstriction causes a brief alteration of blood flow to the brain, causing an acute spasmodic pain of the nose, orbit, face and head.  Its likely the brain’s defense mechanism to ensure abrupt changes in temperature don’t occur.

What’s the treatment?  Stop shoveling ice cream in your mouth!!

Sphenopalatine ganglioneuralgia

This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. Our podcast team is Hector Arreaza, Lisa Manzanares, Roberto Velazquez, and Alyssa Der Mugrdechian. Content review by Carol Stewart. Audio editing by Suraj Amrutia. 

 

References:

New York Times, https://www.nytimes.com/2020/02/24/world/asia/china-coronavirus.html, accessed 2/24/2020 at 10:00 AM, PST.WorldOmetters, Coronavirus, https://www.worldometers.info/coronavirus/NEJM Knowledge+, Question of the Week, accessed on 2/11/2020.Online Epocrates, accessed 02/11/2020, https://online.epocrates.com/diseases/761/Transient-synovitis-of-the-hipKocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am. 1999 Dec;81(12):1662-70.John J and Chandran L. Arthritis in children and adolescents. Pediatr Rev 2011 Nov; 32:470.Huntley JS. Diagnosing and managing hip problems in childhood. Practitioner 2013 Jun; 257:19, 22.